Provider Demographics
NPI:1336193044
Name:VAGOVIC, KANDACE F (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KANDACE
Middle Name:F
Last Name:VAGOVIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 HEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1493
Mailing Address - Country:US
Mailing Address - Phone:386-274-1005
Mailing Address - Fax:386-274-5779
Practice Address - Street 1:517 HEALTH BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1493
Practice Address - Country:US
Practice Address - Phone:386-274-1005
Practice Address - Fax:386-274-5779
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292636900Medicaid
FL292636900Medicaid